Provider Demographics
NPI:1902162662
Name:ACTIVE WELLNESS, LLC
Entity Type:Organization
Organization Name:ACTIVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:INGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-220-9113
Mailing Address - Street 1:4555 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2102
Mailing Address - Country:US
Mailing Address - Phone:773-328-8153
Mailing Address - Fax:
Practice Address - Street 1:4555 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2102
Practice Address - Country:US
Practice Address - Phone:773-328-8153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24800594111N00000X, 111NN1001X, 111NP0017X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8494Medicare PIN